1

British Journal of Clinical Psychology (2020)

© 2020 The Authors. British Journal of Clinical Psychology published by John Wiley & Sons Ltd
on behalf of British Psychological Society.

www.wileyonlinelibrary.com

Brief Report
Schema therapy with exposure and response
prevention for the treatment of chronic anxiety
with comorbid personality disorder
Nancy Peeters1, Sylvie Stappenbelt1, William J. Burk2, Boris
vanPassel1,2 and Julie Krans*1,2
1
Pro Persona Overwaal Centre for Anxiety, OCD, and PTSD, Nijmegen, The
Netherlands
2
Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands

Background and objectives. A considerable group of patients with anxiety disorders

do not respond to guideline CBT treatment, possibly due to comorbid personality
disorder (PD) traits. Schema therapy (ST) is an integrative treatment for personality
disorders, and preliminary evidence suggests that it also affects anxiety. The present study
examined the effects of a combination treatment (‘SCHerp’: ST + exposure and
response prevention) in a non-responsive outpatient group suffering from chronic
anxiety and comorbid cluster C personality disorder.
Methods. Psychological malfunction (n = 42), and adaptive and maladaptive schema
modes (n = 49) were assessed pre- and post-treatment.
Results. Patients showed statistically significant decreases in psychological malfunction
and maladaptive modes, and significant increases in adaptive modes from pre- to post-
treatment. Changes in modes were correlated with changes in psychological malfunction.
Limitations. No control group or follow-up measurements were included.
Conclusions. The combination of ST and exposure with response prevention may be a
viable avenue for research and treatment for this subpopulation. However, further
research is needed to confirm and enhance effectiveness and identify working
mechanisms of SCHerp.

Practitioner points
 The SCHerp programme combines schema therapy with exposure and response prevention to tackle
chronic anxiety in patients with comorbid personality disorder

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which
permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no
modifications or adaptations are made.
*Correspondence should be addressed to Julie Krans, Montessorilaan 3, 6525 HR Nijmegen, The Netherlands (email:
[email protected]).
Sylvie Stappenbelt has moved since this study was undertaken and is now based at [GGNet Scelta Nijmegen, Sint Annastraat
312c, 6525 HG Nijmegen, The Netherlands]

DOI:10.1111/bjc.12271
2 Nancy Peeters et al.

 SCHerp significantly reduced psychological malfunction and maladaptive modes, and increased
adaptive modes
 Changes in schema modes correlated with changes in psychological malfunction, suggesting that
schema modes are an appropriate treatment target in this population
 No active control group was included so no therapy-specific factors can be determined at this stage

In 30–40% of patients with anxiety disorders, symptoms are not alleviated after guideline
cognitive behaviour therapy (CBT) (Clark, 2011; Durham, Chambers, MacDonald, Power,
& Major, 2003). Anxiety disorders show a 12-month comorbidity with (cluster C)
personality disorders (PD) of 40% (Brandes & Bienvenu, 2009; Friborg, Martinussen,
Kaiser, Øverg
ard, & Rosenvinge, 2013; Grant et al., 2005). There is some evidence that
patients with comorbid diagnoses of anxiety and PD show similar improvement in anxiety
symptoms with guideline CBT compared to those without comorbid PD (e.g., Dreessen &
Arntz, 1998; Reich, 2003). However, comorbid diagnoses of PD have also been associated
with worse treatment outcomes for patients diagnosed with anxiety disorders (Reich,
2003; Skodol, Geier, Grant, & Hasin, 2014), decreased confidence in treatment (Martino,
Menchetti, Pozzi, & Berardi, 2012), less stable therapeutic relationships (Bienenfeld,
2007), and elevated dropout (Sanderson, Beck, & McGinn, 1994; but see Olatunji, Cisler,
& Tolin, 2010; Swift & Greenberg, 2012). Thus, although comorbid PD diagnosis is not a
general restriction for guideline CBT for anxiety, a subgroup of chronic non-responders
may require additional intervention. In this naturalistic observational study, we
investigated whether a combination of schema therapy (ST) with exposure and response
prevention (ERP) could provide a potential effective treatment option for a chronic
treatment-resistant subpopulation of patients with anxiety disorders and a comorbid
diagnosis of PD.
Schema therapy was developed for patients with diagnoses of PD who do not respond
to guideline treatment (Young, Klosko, & Weishaar, 2003). A central ST concept is early
maladaptive schemas (EMS), which are described as trait-like dysfunctional thinking
patterns that develop during childhood if basic emotional needs are not met. Triggered
EMS can lead to the activation of schema ‘modes’, which manifest in rapid changes in
mood and behaviour. Anxiety is related to a higher prevalence of EMS (Camara & Calvete,
2012), and EMS may play a role in non-response to CBT (Gross, Stelzer, & Jacob, 2012;
Hoffart, 2012). In ST, patients learn to strengthen the healthy adult mode to deal with
situations that trigger EMS in a more functional way (Young et al., 2003).
Preliminary findings of ST in anxiety are promising. For instance, a combination of
cognitive therapy and ST was more effective than psychodynamic treatment in improving
social functioning of patients with generalized anxiety disorder (Gude & Hoffart, 2008). In
post-traumatic stress disorder (PTSD), reductions in EMS and anxiety were stronger after
ST than CBT (Cockram, Drummond, & Lee, 2010). Gross et al. (2012) reported two
successful cases of the combination of CBT/ST in the treatment of obsessive-compulsive
disorder (OCD). Finally, significant reductions in OCD symptoms were reported in a 12-
week treatment combining ST and exposure in 10 non-responsive patients with OCD and
with or without PD diagnosis (Thiel et al., 2016).
The present study examines changes in psychological malfunction and in schema
modes during a treatment programme called ‘SCHerp’ (SCHema therapy + exposure and
response prevention) in a non-responsive outpatient group with varying anxiety
disorders and comorbid cluster C PD diagnosis. We hypothesized that psychological
malfunction and the level of maladaptive modes would decrease, while the level of
adaptive modes would increase. Reliable change indices and clinically significant changes
 Schema therapy with exposure for comorbidity 3

were also calculated. Correlations among reliable change scores were explored, as
concurrent changes between symptomatology and EMS/modes may be the underlying
mechanism of ST (see Renner et al., 2018; Van Vreeswijk, Spinhoven, Eurelings-Bontekoe,
& Broersen, 2014).

Method
Participants
A convenience sample of 62 outpatients of a specialized mental health care setting for
anxiety, OCD, and PTSD disorders was included (Mage = 34.4, SDage= 9.3; 72.6% female).
Eligibility for the SCHerp programme included a primary diagnosis of an Axis I anxiety
disorder (social anxiety disorder (SAD): n = 26, OCD: n = 19, generalized anxiety
disorder (GAD): n = 10, PTSD: n = 4, panic disorder: n = 3), and a comorbid Axis II
diagnosis of (cluster C) PD, and non-response to previous guideline treatment. See
Supporting information (Participants section) for further details.

Treatment
SCHerp combines ST with exposure and response prevention in a six-month open group
format. For details on the programme, please see Supporting information (Treatment).

Measures
Schema modes
The Schema Mode Inventory (SMI; Young et al., 2007) was used to assess adaptive modes
(happy child and healthy adult) and maladaptive modes (the other 12 modes) (Schaap,
Chakhssi, & Westerhof, 2016). The SMI consists of 124 items rated on a 6-point Likert scale
from 1 (never or hardly ever) to 6 (always). The SMI shows good reliability and validity
(Lobbestael, Van Vreeswijk, Spinhoven, Shouten, & Arntz, 2010). Cronbach’s alpha was
.82 and .93 (T1), and .89 and .95 (T2) for adaptive and maladaptive modes in the current
sample, respectively.

Psychological malfunction
The Outcome Questionnaire-45 (OQ-45; Lambert et al., 1996) is a widely used self-report
questionnaire in outcome research assessing psychological malfunction, suitable for
comparing patients with different diagnoses (Hatfield & Ogles, 2004). The 45 items are
answered on a 5-point Likert scale from 0 (never) to 4 (always) and fall into three
subscales: (1) symptom distress (SD), (2) problems in interpersonal relations (IR), and (3)
problems in social role performance (SR). A cut-off sum score of 63 indicates clinically
significant symptom levels. The OQ-45 possesses good psychometric characteristics (De
Jong & Spinhoven, 2008), with a Cronbach’s alpha of .88 (SD: .89, IR: .72, SR: .43) at T1
and .94 (SD: .94, IR: .81, SR: .66) at T2 in the current study.

Procedure
There were two points of data collection: T1: after the preparatory session and before
treatment start, and T2: at treatment completion. A 3-week leniency criterion was applied.
4 Nancy Peeters et al.

Results
For additional details regarding the statistical approach, descriptive statistics, SMI
reliability analysis, and a description of the correlations reported in Table 1, please see
Supporting information (Statistical approach and Results).

Statistically significant change

Paired samples t-tests indicated statistically significant decreases from T1 to T2 in OQ-45
scores, t(41) = 5.30, p < .001, d = .75, 95% CI [0.43, 1.07] and maladaptive modes, t
(48) = 5.25, p < .001, d = .62, 95% CI [0.36, 0.87]; and statistically significant increases
in adaptive modes, t(48) = 4.40, p < .001, d = .66, 95% CI [ 0.99, 0.33].
Statistically significant decreases were also found for all three subscales of the OQ-45
(see Table S1 inSupporting information).

Reliable and clinically significant change

On the OQ-45 (total scores), reliable deterioration was found for three patients (7.1%, 95%
CI [2.5, 19.0]), indeterminate change for 15 (35.7%, 95% CI [23.0, 50.8]), and reliable
improvement for 24 patients (57.1%, 95% CI [42.2, 70.9]). Clinically significant
improvement was found for 11 patients (26.2%, 95% CI [15.3, 41.1]), who all showed
reliable improvement as well.
For the SMI, reliable deterioration was found for the same three patients on
maladaptive modes (6.1%, 95% CI [2.1, 16.5]), and adaptive modes (6.1%, 95% CI [2.1,
16.5]). Indeterminate change was found for 24 patients on maladaptive modes (49.0%,
95% CI [35.6, 62.5]) and for 30 patients on adaptive modes (61.2%, 95% CI [47.2,
73.6]). Reliable improvement was found for 22 patients on maladaptive modes
(44.9%, 95% CI [31.9, 58.7]) and 16 patients on adaptive modes (32.7%, 95% CI [21.2,
46.6]).
Correlations between reliable change on the OQ-45 and adaptive modes (r = .64,
95% CI [ 0.81, 0.39], p < .001) and maladaptive modes (r = .58, 95% CI [0.30,
0.77], p < .001) were statistically significant, indicating indicate that decreases in
malfunctioning are associated with increases in adaptive modes and decreases in
maladaptive modes.

Table 1. Correlations among pre- and post-treatment measurements

Variable 1 2 3 4 5 6

1. T1 OQ-45 –
2. T2 OQ-45 .58** –
3. T1 SMI-Mal .24 .17 –
4. T2 SMI-Mal .28 .59** .66** –
5. T1 SMI-Ad –.63** –.34* –.49** –.31* –
6. T2 SMI-Ad –.50* –.76** –.15 –.56** .45* –

Note. T1 = pre-treatment; T2 = Post-treatment; OQ-45 = Outcome Questionnaire-45; SMI =

Schema Mode Inventory; Mal = maladaptive modes; Ad = adaptive modes.
*p < .05; **p < .001.
 Schema therapy with exposure for comorbidity 5

Discussion
Consistent with our first hypothesis, there was a statistically significant decrease in
psychological malfunction, with a medium effect size, during SCHerp. All three subscales
of the OQ-45 decreased significantly, indicating impact on anxiety symptoms as well in the
symptom distress subscale. In line with the second hypothesis, maladaptive modes
significantly decreased, whereas adaptive modes significantly increased, also with
medium effect sizes. About a third to half of the patients reached reliable improvements on
psychological malfunction, maladaptive and adaptive modes (57.1, 44.9, and 32.7%,
respectively). A quarter of the patients (26.2%) reached clinically significant improve-
ments on psychological malfunction. Moreover, changes in psychological malfunction
were associated with changes in both adaptive and maladaptive modes.
These findings are in line with the study by Thiel et al. (2016), which first showed the
effectiveness of a programme similar to SCHerp in a pilot of 10 patients with OCD with or
without diagnoses of cluster C PD. Effect sizes found in this study are also comparable to
research on combined group ST and CBT in patients with PD diagnosis (Renner, Arntz,
Leeuw, & Huibers, 2013). With regard to clinical significance, the results are more modest
than in previous studies. In a short-term group ST with a heterogeneous patient group, Van
Vreeswijk et al. (2014) found reliable and/or clinically significant improvement in general
distress in about half of the patients, and an indeterminate change in about a third of patients.
However, the majority of these patients did not have any comorbidity. Schaap et al. (2016),
who investigated an inpatient ST programme for non-responding patients with PD diagnosis,
found reliable improvement in 70–85% of patients regarding general distress as well as (mal)
adaptive modes. Their treatment lasted 12 months, and not all patients showed comorbidity.
Notably, patients in the current study showed relatively small improvements in adaptive
modes. This finding is important as improvement in symptoms was more strongly correlated
with adaptive than maladaptive modes. This implies that SCHerp may be improved by
focusing on further strengthening adaptive schema modes. The correlated change between
psychological malfunction and modes is comparable to the findings by Renner et al. (2018)
and Van Vreeswijk et al. (2014) and suggests concurrent associations between changes in
anxiety symptoms and schema modes. However, the absence of intermediate measurement
points prohibits conclusions about potential mediation.
There are several limitations to the present study. First, this was a naturalistic
observational study, which has benefits in terms of ecological validity, but obvious
limitations in drawing causal conclusions about effectiveness. A next step could be a
comparison with a passive control condition, such as a natural waiting list. Comparisons
with active evidence-based treatments, such as guideline CBT and pharmacotherapy, will
be informative. However, these designs would have ethical objections as the target
population by definition did not respond to guideline treatment. Currently, it is unclear
what active control group would be best suited for a comparison. In addition, studies
dismantling the working mechanisms are needed. Examining changes in specific modes,
EMS, and symptoms by including one or more intermediate measurements points during
treatment could provide further insight into the sequential changes in modes and anxiety
symptoms. Moreover, assessing session-to-session or weekly changes could advance our
knowledge on the effects of specific therapy processes (see Renner et al., 2018).
Second, although both statistical and clinically significant changes were found in this
study, still a significant proportion of patients did not benefit sufficiently. This indicates
that the programme can be further improved, for which effectiveness and dismantling
studies will be important. The lack of follow-up measurements prevents us from making
6 Nancy Peeters et al.

conclusions about long-term clinical gains. Third, the moderate sample size and
heterogenous sample did not allow for a multivariate approach or a more detailed
analyses of specific modes or disorder-specific symptoms. Furthermore, aggregation of
SMI subscales into adaptive and maladaptive schema mode composite scores was based
on earlier research (Schaap et al., 2016) and showed adequate internal consistencies in
our sample, yet a factor analysis is needed to validate this approach empirically.
Overall, this study aimed to contribute to research on chronic and treatment-resistant
anxiety in order to develop treatment options for this specific population. Our study
showed that a combination of ST and CBT may be helpful. ST techniques may also provide
clinicians with a rationale for dealing with behaviours that could hinder exposure. Clinical
observations showed a low dropout rate (6% in our sample), which is encouraging. Given
the methodological limitations, further controlled research is needed to study effective-
ness and working mechanisms of ST combined with ERP for chronic anxiety with
comorbid PD diagnoses.

Ethical statement
Anonymous data from electronically registered routine outcome monitoring were used
for this study. As this data does not relate to an identified or identifiable natural person, it
does not fall under the European General Data Protection Regulation (General Data
Protection Regulation, 2020). Patients were not submitted to any specific action or
intervention for the study, measures and assessment procedure were part of usual care.
Therefore, according to Dutch Law on Medical Ethics, no specific informed consent or a
review of a Medical Ethical Committee was required, although patients provided a general
consent for use of this type of anonymous data for research purposes as standard intake
procedure at which they received the SCHerp programme.

Acknowledgements
We thank Judith Appel and Rosa Pranger for their substantial help with organizing the dataset,
the statistical analyses, and writing of the manuscript. We thank all included patients for
completing the Routine Outcome Monitoring questionnaires during their time in the SCHerp
programme.

Conflict of interest
All authors declare no conflict of interest.

Funding
This research did not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors.

Author contributions
Nancy Peeters (Data curation; Formal analysis; Software; Writing – review & editing)
Sylvie Stappenbelt (Conceptualization; Writing – original draft) William J Burke (Data
 Schema therapy with exposure for comorbidity 7

curation; Formal analysis; Methodology; Writing – original draft; Writing – review &
editing) Boris van Passel (Conceptualization; Data curation; Project administration;
Supervision; Writing – original draft; Writing – review & editing) Julie Krans (Concep-
tualization; Data curation; Formal analysis; Methodology; Project administration;
Resources; Supervision; Writing – original draft; Writing – review & editing).

Data availability statements

Due to internal policies of the mental health care institute where these data were collected
the dataset used in this article, it is not publicly available. However, anonymized data can
be obtained from the corresponding author upon request.

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Received 11 March 2020; revised version received 23 October 2020

Supporting Information
The following supporting information may be found in the online edition of the article:
Table S1. T1 and T2 scores of the OQ-45 subscales.